Staff-model Health Maintenance Organization Research Articles

Prevalence of Renal and Cervical Vertebral Anomalies in Patients With Isolated Microtia and/or Aural Atresia.

The objective of this study was to determine whether patients with isolated microtia or aural atresia have an increased prevalence of renal or cervical vertebral anomalies. The study design was a retrospective medical record review. The setting was the following four distinct institutions: an urban tertiary care children's hospital, two urban academic medical centers, and a staff-model health maintenance organization. Patients diagnosed with microtia, aural atresia, or oculoauriculovertebral spectrum were identified. Patients with facial asymmetry, craniofacial microsomia, and other craniofacial abnormalities or syndromes were excluded. Main outcome measures were the number of patients with isolated microtia or aural atresia who underwent a renal ultrasound or cervical spine X-ray, the results of those studies, and further evaluation or treatment for any abnormalities found. A binomial analysis using a one-sided 95% confidence level was performed. A total of 514 patients with isolated microtia and/or aural atresia were identified. Of these patients, 145 (28%) had undergone a renal ultrasound and 81 (16%) had undergone cervical spine X-rays. A total of 3 patients (2%) had minimal renal pelviectasis, all of which had resolved on repeat ultrasound and required no treatment. There were no structural renal abnormalities identified, and there were no cervical spine abnormalities identified. The data suggest that there is no increased prevalence of structural renal or cervical vertebral anomalies in patients with isolated microtia and/or aural atresia. Therefore, these patients do not require routine screening renal ultrasound or cervical spine X-rays.

Influenza Antiviral Expenditures and Outpatient Prescriptions in the United States, 2003-2012.

The clinical efficacy and cost-effectiveness of influenza antiviral use are controversial, with recent analyses suggesting potentially limited value. Thus, the objectives of this study were to describe influenza antiviral expenditures overall and by health care setting over a 10-year period (2003-2012) and to assess the correlation between outpatient influenza antiviral prescription use and influenza-like illness (ILI) outpatient visits. Retrospective, cross-sectional study. IMS Health National Sales Perspectives and Xponent databases and Centers for Disease Control and Prevention ILINet national influenza surveillance system database. All prescriptions for oseltamivir, rimantadine, or zanamivir from community pharmacies, mail order pharmacies, clinics, nonfederal hospitals, and other health care settings (federal hospitals, military facilities, jails and prisons, universities, staff-model health maintenance organizations, veterinary hospitals and clinics, and long-term care facilities) between January 1, 2003, and December 31, 2012. Prescribing rates were calculated (prescriptions/1000persons) for each year from 2003 to 2012 by using U.S. Census Bureau data. Influenza season was defined as July 1-June 30 of each calendar year. Linear regression assessed the correlation between influenza antiviral expenditures, prescription use, and ILI diagnoses. From 2003 to 2012, influenza antiviral drug expenditures accounted for $3.74 billion, with the majority from community pharmacies. After adjusting for inflation, no growth was observed for expenditures. A total of 32.8 million influenza antiviral prescriptions were dispensed from community pharmacies during the study period, and these prescriptions experienced 133.2% growth from 2003 to 2012. One third of expenditures and one quarter of dispensed prescriptions were in 2009. Influenza seasons were correlated with ILI and antiviral prescriptions. Annual community pharmacy expenditures were also associated with influenza antiviral prescriptions dispensed over the 10-year period. Influenza antivirals totaled $3.74 billion in the United States from 2003 to 2012, with the majority in 2009 and from community pharmacies. Influenza antivirals constituted a small proportion of total medication expenditures, but unforeseen pandemics resulted in unusually high use and expenditures. Influenza antiviral prescriptions dispensed from community pharmacies were associated with ILI and drug expenditures.

Evaluating the Psychometric Properties of the CAHPS Patient-Centered Medical Home Survey

ObjectiveThe goal of this study was to evaluate the reliability and validity of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Patient-Centered Medical Home (PCMH) survey. MethodsWe conducted a field test of the CAHPS PCMH survey with 2740 adults. We collected information by mail (n = 1746), telephone (n = 672), and from the Web (n = 322) from 6 sites of care affiliated with a West Coast staff model health maintenance organization. ResultsAn overall response rate of 37% was obtained. Internal consistency reliability estimates for 7 multi-item scales were as follows: access to care, 5 items, α = 0.79; communication with providers, 6 items, α = 0.93; office staff courtesy and respect, 2 items, α = 0.80; shared decision making about medicines, 3 items, α = 0.67; self-management support, 2 items, α = 0.61; attention to mental health issues, 3 items, α = 0.80; and care coordination, 4 items, α = 0.58. The number of responses needed to get reliable information at the site of care level for the composites was generally acceptable (<300 for 0.70 reliability-level) except for self-management support and shared decision making about medicines. Item-scale correlations provided support for distinct composites except for access to care and shared decision making about medicines, which overlapped with the communication with providers scale. Shared decision making and self-management support were significantly, uniquely associated with the global rating of the provider (dependent variable), along with access and communication in a multiple regression model. ConclusionsThis study provides further support for the reliability and validity of the CAHPS PCMH survey, but refinement of the self-management support and shared decision-making scales is needed. The survey can be used to provide information about the performance of different health plans on multiple domains of health care, but future efforts to improve some of the survey items is needed.

Advanced Age as a Risk Factor for Folate‐Associated Functional Cobalamin Deficiency

To determine whether high serum folate levels contribute to metabolite changes in elderly subjects with normal cobalamin levels. Case series. Outpatient clinic at a university-based staff model health maintenance organization. Two hundred thirty-three ambulatory individuals without diabetes mellitus with normal renal function and normal cobalamin levels evaluated for cobalamin deficiency. Cobalamin, serum folate, methylmalonic acid (MMA), and homocysteine. Older individuals (≥60) with low-normal cobalamin levels (201-300pg/mL) had higher MMA and lower homocysteine levels when serum folate levels were high (>20ng/mL) than when serum folate levels were normal (P<.02), but serum folate levels within the normal range were not a determinant of either metabolite. In younger subjects with low-normal cobalamin levels, high serum folate levels were not associated with significant differences in either metabolite. At mid-normal cobalamin levels (301-600pg/mL), high serum folate levels were associated with lower homocysteine levels in older adults (P<.001) but not with differences in MMA in either age group. Cobalamin therapy decreased or normalized MMA and homocysteine in 89% or more of participants even at pretherapy cobalamin levels greater than 600pg/mL. High serum folate levels are associated with higher MMA levels when cobalamin levels are low-normal, and this effect is age dependent, not progressive within the normal serum folate range (suggesting a threshold effect), and reversed by cobalamin therapy. Because MMA may be neurotoxic, these findings suggest caution in the use of folic acid supplements in elderly adults.

Community-Created Programs: Can They Be the Basis of Innovative Transformations in Our Health Care Practice? Implications from 15 Years of Testing, Translating, and Implementing Community-Based, Culturally Tailored Diabetes Management Programs

D iabetes prevalence is predicted to rise dramatically during the next 20 years, and associated spending is expected to increase threefold.1–3 Cultural barriers contribute to this burden by preventing optimal care among diverse ethnic groups that are at elevated risk for high-cost complications.4–10 Culturally appropriate, clinically sound, and cost-effective models are needed to respond to the growing and diverse populations affected by diabetes worldwide. Chronic disease now accounts for 75% of the $2 trillion in annual medical costs in the Untied States, and adherence to prescription regimens among those with chronic conditions is estimated to range from 20 to 50%.11,12 Nonadherence to medications accounts for ~ $100 billion in annual health care costs.13,14 Health care reform is a driving force to identify low-cost and clinically effective interventions to improve health care quality and reduce costs. Nontraditional care management models, innovative technologies to improve patient adherence to prescribed medical regimens, and use of adherence-enhancing strategies in clinical practice would greatly enhance the health impact of efficacious treatments and prevention efforts and consequently reduce the burden of nonadherence-related health care costs. The most recognized approach for improving care through the current health care delivery system is the Chronic Care Model (CCM) developed by Ed Wagner et al.15–18 This model recognizes that a substantial portion of chronic care management takes place outside of formal health delivery settings. Patient self-management, delivery system design (including information systems and decision-support tools), and community resources are crucial components of this model. The CCM has been used successfully in staff-model health maintenance organizations, large group practices, and community health clinics, and its implementation has been shown in numerous studies to improve care in diabetes and other chronic diseases.19 The medical home model …

Guideline Adherence and Outcomes in Esophageal Variceal Hemorrhage

Implementation of consensus guidelines for esophageal variceal hemorrhage yields improved outcomes. We evaluated guideline adherence and outcomes after variceal hemorrhage at a university hospital (UH) and a staff-model health maintenance organization (HMO). Factors associated with short-term bleeding, infection, and death were retrospectively identified in UH (n=160) and HMO (n=123) patients with esophageal variceal hemorrhage from January 2000 to December 2006. A second analysis of factors associated with long-term rebleeding was conducted in patients who survived ≥14 days without rebleeding. UH patients were younger, with more severe liver disease and overall illness (P<0.01). UH patients more often received vasoactive agents and prophylactic antibiotics (P<0.01), however the rate of endoscopic therapy did not differ. Infections at 14-days were similar (18.2% vs. 13.0%, P=0.25), but UH patients had greater in-hospital rebleeding (16.4% vs. 5.7%, P<0.01) and mortality (15.2% vs. 4.1%, P<0.01). Poor liver function and overall illness predicted infection, rebleeding, and death (adjusted odds ratio 2.75 to 13.39). Long-term rebleeding occurred in 36.1% of UH patients and 25.9% of HMO patients. Secondary prophylaxis reduced late rebleeding (hazard ratio 0.37 to 0.41). Poor liver function did not predict late rebleeding. Adherence to secondary prophylaxis was greater at the HMO (P<0.05), but late rebleeding did not differ (36% vs. 26%, P=0.13). Irrespective of practice setting, poor liver function and critical illness predicted short-term bleeding, infection, and death after esophageal variceal hemorrhage, and secondary prophylaxis prevented long-term rebleeding. Differing guideline adherence did not influence outcomes between tertiary care and non-tertiary care centers.

Diagnostic Accuracy of Predicting Somatization From Patients’ ICD-9 Diagnoses

To hypothesize in a new and different population that administrative database (ADB) screening would identify somatizing patients by increasing numbers of visits, female gender, and greater percent of International Classification of Diseases, 9th Edition (ICD-9) primary diagnosis codes in musculoskeletal, nervous, gastrointestinal (GI), and ill-defined body systems. We labeled these codes as having "somatization potential." Our earlier study demonstrated that ICD-9 codes and other data from the ADB effectively identified somatization. Using a prospective observational design in a staff model health maintenance organization, we evaluated 1364 patients aged 18 to 65 years who had > or =8 visits yearly in the 2 years before study. Clinician raters applied a reliable method of medical chart review to identify patients meeting the criteria for somatization. We randomly selected 2/3 for the derivation set (n = 901) for logistic regression to evaluate the contribution of potential ADB correlates (age, gender, all encounters, primary diagnosis codes (ICD-9), revenue codes, and charges) of a diagnosis of somatization. This prediction rule was then applied to the remaining 1/3 of subjects, the validation set (n = 463). Patients averaged 47.1 years, 12.8 visits per year, and 71.6% were female; 319 had somatization. Age, visits, and somatization potential were associated with clinician-rated somatization, with a c-statistic 0.72 in the derivation set and 0.68 in the validation set. These data support our earlier findings that selected ICD-9 diagnoses in the ADB predict somatization, suggesting their potential in identifying a common, costly, and usually unrecognized problem.

A pharmacy leadership action study

ObjectiveTo report on the creation of a leadership development program targeted exclusively at pharmacists working in management in the professional community. SettingLarge staff-model health maintenance organization (HMO) in California between 2004 and 2008. Practice descriptionThe Pharmacy Leadership Institute (PLI; a joint effort of the School of Pharmacy and the Center for the Health Professions at the University of California, San Francisco) tested a program in a large staff-model HMO with hundreds of pharmacists in leadership roles. This program included learning seminars, psychometric assessments, leadership goals, intersession activities, coaching/mentoring, and leadership projects. Practice innovationNot applicable. Main outcome measuresPLI collected survey data in order to evaluate the effectiveness of the institute's leadership development program. In addition, an external evaluator was hired to conduct interviews with the pharmacy directors of the organization which chose to pilot the program. ResultsThe evaluations from the participants indicate that the leadership development program met many but not all of its initial objectives. Consistent with action research methodology, the faculty of the institute met to redesign some sections of the program in order to meet the established goals. Adjustments were made to different components of the program over the next 4 years. Evaluation data show that these revisions were successful. In addition, follow-up evaluations with participants showed a lasting impact of the program on both individual leadership skills and organizational outcomes. ConclusionGiven the positive outcomes indicated by the evaluation data used in this study, the work of PLI indicates that broader leadership skills can be identified and enhanced within a group of pharmacy managers.

Costs of an intervention for primary care patients with medically unexplained symptoms: a randomized controlled trial.

This study sought to determine whether an intervention for patients with medically unexplained symptoms in primary care reduced total costs, components of cost, and longer-term costs and whether it led to decreased service use outside the health maintenance organization (HMO). A randomized controlled trial involving 206 patients with medically unexplained symptoms was conducted in a staff-model HMO. The protocol emphasized the provider-patient relationship and included cognitive-behavioral therapy and pharmacological management. Cost data for medical treatments were derived from the HMO's electronic database. Patients were interviewed about work days lost and out-of-pocket expenses for medical care outside the HMO. The difference in total costs ($1,071) for the 12-month intervention was not significant. The treatment group had significantly higher costs for antidepressants than the usual-care group ($192 higher) during the intervention, and a larger proportion received antidepressants. The intervention group used less medical care outside the HMO and missed one less work day per month on average (1.23 days), indicating a slight improvement in productivity, but the difference was not significant. The between-group difference in estimated total cost was smaller in the year after the intervention (difference of $341) but were not significant. The total costs for the intervention group were not significantly different, but the group had greater use of antidepressants. Coupled with findings of improved mental health outcomes for this group in a previous study, the results indicate that the intervention may be cost-effective. The longer-term impact needs to be further studied.

Costs of an Intervention for Primary Care Patients With Medically Unexplained Symptoms: A Randomized Controlled Trial

This study sought to determine whether an intervention for patients with medically unexplained symptoms in primary care reduced total costs, components of cost, and longer-term costs and whether it led to decreased service use outside the health maintenance organization (HMO).A randomized controlled trial involving 206 patients with medically unexplained symptoms was conducted in a staff-model HMO. The protocol emphasized the provider-patient relationship and included cognitive-behavioral therapy and pharmacological management. Cost data for medical treatments were derived from the HMO's electronic database. Patients were interviewed about work days lost and out-of-pocket expenses for medical care outside the HMO.The difference in total costs ($1,071) for the 12-month intervention was not significant. The treatment group had significantly higher costs for antidepressants than the usual-care group ($192 higher) during the intervention, and a larger proportion received antidepressants. The intervention group used less medical care outside the HMO and missed one less work day per month on average (1.23 days), indicating a slight improvement in productivity, but the difference was not significant. The between-group difference in estimated total cost was smaller in the year after the intervention (difference of $341) but were not significant.The total costs for the intervention group were not significantly different, but the group had greater use of antidepressants. Coupled with findings of improved mental health outcomes for this group in a previous study, the results indicate that the intervention may be cost-effective. The longer-term impact needs to be further studied.

Who Will Do the Work? What Work Will They Do?

in the United States. 2 This first-pass determination was done during a time when the expense of oncology care was starting to become an issue, in an era of more rudimentary cancer treatments, and on a background of proposals to reduce oncologytraining slots by 40%. The then-estimated 3,600 full-time-equivalent oncologists were adequate, based on comparisons with staff model health maintenance organizations’ (HMOs) use of oncologists per 100,000 population. Though this estimate of the workforce size was almost certainly wrong, the earlier study’s two main conclusions are largely true: oncologists desired delivering less primary care, and the workforce was right-sized. Fifteen years on, most oncologists are as busy as they want to be, and they spend their professional time delivering specialty oncology care. The current study used many data sources (both existing and new data from four surveys) to provide a more reliable estimate of the current oncology workforce—the American Medical Association Masterfile of physicians—and a more robust estimate of the potential patient population and oncology practice patterns. The results indicate that we will be facing a shortage of 2,550 to 4,080 oncologists by 2020 —which could translate to 9.4 to 15 million fewer oncologist visits. The study used a combination of Medicare visit data and National Cancer Institute incidence and prevalence projections to determine the demand for services and capacity of the workforce to deliver those services. The authors performed sensitivity analyses, testing the effects of increasing oncology training slots, electronic medical record use, and midlevel provider use on visit capacity and workforce supply. Projections were also made on the effects of delaying retirement of current oncologists and potential for decreased work hours and thus productivity in younger oncologists. The model’s sensitivity to increases in the number of new cancer patients seen by an oncologist, to varying the intensity of oncologist interaction with each patient, and to truncation of oncologist interaction with each patient by use of hospice or primary care providers to manage various stages of the illness was tested. Making predictions, especially about the future, is difficult, as was observed by both the theoretical physicist Niels Bohr and the applied physicist Yogi Berra. The wildest swings in the predictive model for visit demand (Table 4) occur when the proportion of new cancer cases seen by an oncologist is varied. 1 Many other specialists manage early-stage colon, skin, and prostate cancers. Medical oncologists add little value to management of these early-stage tumors, but radical changes in the management of these conditions (effective adjuvant systemic therapy for early-stage, high-risk prostate and colon cancers for instance) could radically alter the demand forecast. On the contrary, simplification in the management of hormone receptor–positive early-stage breast cancer could lead to more management of this now-common condition by surgeons or other nononcologists. It is difficult to predict the changes in practice patterns that biomedical or information technology will bring 15 years from now. Market forces should be allowed to continue to guide adjustments of oncology care. The reason medical oncologists see less early-stage prostate and skin cancer is that we currently add little value to the care of these patients. As oncologists become relatively rarer and our time more dear, we will figure out ways to become more productive diagnosticians, innovators, and problem solvers. We will spend less professional time performing extensive documentation and other non–value-added tasks, and more time developing and leading our teams. We should develop and refine guideline-based care so that we can delegate more routine tasks to midlevel providers, experienced oncology nurses, and others who specialize in managing various aspects of the cancer care continuum. Information technology should be developed to allow us to spend more productive time with our patients. Those new associates who are identified and hired should add value to patient care and only do work for which a trained medical oncologist is required.

Changes in the Quality of Care for Bipolar I Disorder During the 1990s

Changes in the Quality of Care for Bipolar I Disorder During the 1990s

Vagus nerve stimulation therapy for pharmacoresistant epilepsy: Effect on health care utilization

We retrospectively analyzed the effects of vagus nerve stimulation (VNS) therapy on utilization of medical services by 138 patients in a large staff-model health maintenance organization. We compared average quarterly rates for 12 months before device implantation with quarterly rates during 48 months of follow-up. Wilcoxon matched-pairs signed-ranks tests comparing pre-VNS with post-VNS utilization rates showed statistically significant reductions in numbers of emergency department visits, hospitalizations, and hospital lengths of stay, beginning with the first quarter after implantation ( P < 0.05 for all post-implantation quarters for these three aspects). For the first two quarters after implantation, the average number of outpatient visits was significantly greater than the pre-implant quarterly average (quarter 1: P < 0.0001; quarter 2: P = 0.0067), but the average was 12.2% less by the fourth quarter of the first year after implantation and significantly less beginning with the first quarter of the second year ( P = 0.0017) and continuing through the end of the study ( P < 0.0001 for all subsequent quarters). A comparison of time spent on epilepsy-related tasks during the year before implantation with the year after implantation also revealed significant decreases in the average number of days on which patients could not work because of health-related concerns, from 3.67 to 1.04 days ( P = 0.002, paired Student’s t test) and the average time spent caring for health problems, from 352.6 to 136.1 minutes per week ( P < 0.001). VNS therapy had a positive effect on both the utilization of health care services and the time spent on epilepsy-related tasks for these patients with pharmacoresistant epilepsy.

Asthma Symptom Burden: Relationship to Asthma Severity and Anxiety and Depression Symptoms

The purpose of this work was to examine the relationship between youth-reported asthma symptoms, presence of anxiety or depressive disorders, and objective measures of asthma severity among a population-based sample of youth with asthma. We conducted a telephone survey of 767 youth with asthma (aged 11-17 years) enrolled in a staff model health maintenance organization. The Diagnostic Interview Schedule for Children was used to diagnose Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, anxiety and depressive disorders; the Child Health Status-Asthma questionnaire (modified) was used to assess asthma symptoms; and automated administrative data were used to measure asthma treatment intensity and severity. Analyses of covariance were performed to determine whether the number of anxiety and depressive symptoms was related to the number of asthma symptoms. Logistic regression analyses were used to evaluate the strength of association between individual symptoms of asthma and the presence of an anxiety or depressive disorder and objective measures of asthma severity. After adjusting for demographic characteristics, objective measures of asthma severity, medical comorbidity, and asthma treatment intensity, youth with > or = 1 anxiety or depressive disorder (N = 125) reported significantly more days of asthma symptoms over the previous 2 weeks than youth with no anxiety or depressive disorders. The overall number of reported asthma symptoms was significantly associated with the number of anxiety and depressive symptoms endorsed by youth. In logistic regression analyses, having an anxiety or depressive disorder was also strongly associated with each of the 6 asthma-specific symptoms, as well as the 5 related nonspecific somatic symptoms contained in the Child Health Status-Asthma questionnaire. The presence of an anxiety or depressive disorder is highly associated with increased asthma symptom burden for youth with asthma.

Retrospective review of sex differences in the management of dyslipidemia in coronary heart disease: An analysis of patient data from a Maryland-based health maintenance organization

Background: Coronary heart disease (CHD) is the leading cause of death in men and women in the United States, with a higher mortality in women, despite a lower prevalence. Statins effectively treat dyslipidemia and reduce the risk of CHD mortality. Objective: The objective of this study was to evaluate the treatment of dyslipidemia in patients with CHD and determine if sex differences exist. Methods: This was a retrospective chart review performed within a multioffice staff model health maintenance organization of ∼70,000 members. An administrative database, containing inpatient and out-patient medical claims, was used to identify patients with CHD based on diagnostic codes. Charts were randomly selected and the following information was obtained from chart review: age; sex; risk factors for CHD; diagnosis and/or prescription for depression; blood low-density lipoprotein cholesterol (LDL-C) level; and drug, dosage, and duration of prescribed lipid-lowering therapy. Exclusion criteria included missing charts and unavailable LDL-C values. LDL-C values were classified as at target if LDL-C <2.59 mmol/L (<100 mg/dL). Patients receiving statin monotherapy were categorized into 3 potency groups, based on efficacy to lower LDL-C values: high (atorvastatin 20–80 mg, lovastatin 80 mg), medium (atorvastatin 10 mg, pravastatin 40 mg, simvastatin 200 mg), and low (fluvastatin 10–40 mg, lovastatin 10–40 mg, pravastatin 10–20 mg, simvastatin 5–10 mg). Results: A total of 1487 adult patients (64.4% male with a mean (SD) age of 65.7 (11.8) years were identified, based on diagnostic codes for CHD. Three hundred twenty charts were selected for review. After exclusion, the final study cohort was 290 patients. The cohort was 66.2% male (192/290) with no significant difference in mean (SD) age between men (65.2 [9.2] years) and women (66.9 [10.5] years). Weight of women ranged from 85 to 305 lbs; 134 to 288 lbs for men. Among the study cohort, 46.2% (134/290) of the patients achieved the target LDL-C of <2.59 mmol/L (<100 mg/dL), with significantly more men (51.0% [98/192]) than women (36.7% [36/98]) reaching target ( P = 0.021). Lipid-lowering therapy was prescribed to 68.6% (199/290) of the patients, with no significant sex differences (men, 71.4% [137/192]; women, 63.3% [62/98]). Of the patients prescribed lipid-lowering therapy (primarily statins), 53.8% (107/199) achieved target LDL-C. There was no significant sex difference in the potency groups prescribed, and the rate of LDL-C target attainment was similar across potency groups. Overall, 70.3% of patients who did not receive lipid-lowering therapy had inadequately controlled LDL-C (women, 31/36 [86.1 %]; men, 33/55 [60.0%] [ P = 0.008]). Conclusions: The majority of CHD patients from a Maryland-based health maintenance organization had elevated LDL-C values, despite a lipid-lowering prescription rate of 68.6%. A significant gap in dyslipidemia treatment in these CHD patients remained, particularly for women.

Going beyond the Kidney Disease Outcomes Quality Initiative: Hemodialysis Access Experience at Kaiser Permanente Southern California

In 1996, as part of Kaiser Permanente Southern California's participation in the Medicare End-Stage Renal Disease Managed Care Demonstration Project, a multidisciplinary continuous quality improvement (CQI) committee was formed, which included nephrologists, vascular surgeons, interventional radiologists, care managers, a renal quality-improvement nursing director, and renal program administrators. The goal of this report was to analyze the impact of this CQI program on hemodialysis outcomes within the organization. Kaiser Permanente is a national, integrated, nonprofit, staff model health maintenance organization with 8 million members. The southern California region has 3.1 million members and currently manages the health care of 3,700 hemodialysis patients, 300 peritoneal dialysis patients, and 1,000 kidney transplant patients. Thirty-one vascular surgeons and 29 interventional radiologists provide for their hemodialysis access needs. The Kidney Disease Dialysis Outcomes Quality Initiative (K/DOQI) guidelines were adopted, as well as measures to perform more venous transpositions and less common arteriovenous fistulas (AVFs) before graft placement. The outcomes assessed included incidence and prevalence of AVFs, grafts, and catheters; replacement access with AVFs; and combined AVF and graft thrombosis episodes per patient per year. Primary AVF incidence rates increased from 27% in 1997 to 88% in 2003. AVF prevalence rates increased from 30% in 1997 to 62% in 2003. Replacement access which is an AVF increased from 26% in 1998 to 58% in 2003. Yearly thrombosis episodes/patient decreased from 0.62 in 1998 to 0.34 in 2003. Catheter usage as of 2003 comprised an incidence of 65% and prevalence (> or =90 days) of 13%, which was essentially unchanged from 1999, despite improvements in fistula usage and thrombosis rate. The rate of AVF prevalence can be increased dramatically, exceeding the 40% K/DOQI recommendation, by using the CQI process. Increased prevalence of AVF is associated with a lower yearly incidence of thrombosis episodes/patient. Reducing excessive catheter usage appears to be a more difficult problem.

Improved asthma outcomes from allergy specialist care: A population-based cross-sectional analysis

Prior studies suggest that allergist care improves asthma outcomes, but many of these studies have methodological shortcomings. We sought to compare patient-based and medical utilization outcomes in randomly selected asthmatic patients cared for by allergists versus primary care providers. A random sample of 3568 patients enrolled in a staff model health maintenance organization who were given diagnoses of persistent asthma completed surveys. Of these participants, 1679 (47.1%) identified a primary care provider as their regular source of asthma care, 884 (24.8%) identified an allergist, 693 (19.4%) reported no regular source of asthma care, and 195 (5.5%) identified a pulmonologist. Validated quality of life, control, severity, patient satisfaction, and self-management knowledge tools and linked administrative data that captured medication use were compared between groups, adjusting for demographics and baseline hospital and corticosteroid use. Compared with those followed by primary care providers, patients of allergists reported significantly higher (P < .001) generic physical and asthma-specific quality of life, less asthma control problems, less severe symptoms, higher satisfaction with care, and greater self-management knowledge. Patients of allergists were less likely than patients of primary care providers to require an asthma hospitalization (odds ratio, 0.45) or unscheduled visit (odds ratio, 0.71) and to overuse beta-agonists (odds ratio, 0.47) and were more likely to receive inhaled steroids (odds ratio, 1.81) during their past year. Allergist care is associated with a wide range of improved outcomes in asthmatic patients compared with care provided by primary care providers.

Improving Detection of Suicidal Ideation Among Depressed Patients in Primary Care

Primary care clinicians have difficulty detecting suicidal patients. This report evaluates the effect of 2 primary care interventions on the detection and subsequent referral or treatment of patients with depression and recent suicidal ideation. Adult patients in 12 mixed-payer primary care practices and 9 not-for-profit staff model health maintenance organization (HMO) practices were screened for depression. Matched practices were randomized within plan type to intervention or usual care. The intervention for mixed-payer practices entailed brief training of physicians and office nurses to provide care management. The intervention for HMO practices consisted of guided development of quality improvement teams for depression care. A total of 880 enrolled patients met study criteria for depression, 232 of whom met criteria for recent suicidal ideation. Intervention effects on suicide detection and referral to mental health specialty care were evaluated with mixed-effects multilevel models in intent-to-treat analyses. Depressed patients with recent suicidal ideation were detected on 40.7% of index visits in intervention practices, compared with 20.5% in usual care practices (odds ratio = 2.64, 95% confidence interval, 1.45-5.07), with HMO plan type and male sex associated with detection. The interventions had no effect on referral of patients, starting an antidepressant, or suicidal ideation reported at a 6-month follow-up, although power was limited for all 3 analyses. Primary care interventions to improve depression care can improve detection of recent suicidal ideation. Further work is needed to improve physician response to detection, including referral to specialty care and more aggressive treatment, and to observe the effect on outcomes.

Quality of Care of Medicare Patients With Diabetes in a Metropolitan Fee-for-Service Primary Care Integrated Delivery System

Diabetes care in the United States is suboptimal. Although closed-panel health maintenance organizations (HMOs) and the Department of Veterans Affairs (VA) report performance superior to national norms, fee-for-service performance is uncertain. To address this issue, 3 outcome and 5 process indicators were measured for 2010 Medicare diabetes patients across 22 sites in a large, fee-for-service primary care group practice. American Diabetes Association standards for glycemic control, low-density lipoprotein cholesterol, and blood pressure were met by 53%, 46%, and 19% of patients, respectively. Diabetes Quality Improvement Project/Alliance poor control markers for the same measures were exceeded by 9%, 20%, and 54% of patients. Chart abstraction demonstrated annual eye examination, foot examination, and nephropathy screening rates of 16%, 49%, and 38%, while Medicare claims showed an annual eye examination rate of 63%. Observed processes and outcomes in this fee-for-service setting were superior to reported national performance and similar to the best performance in staff-model HMOs and the VA.

Achieving Cholesterol Target in a Managed Care Organization (ACTION) Trial

To objectively compare the results of a collaborative approach using pharmacists with the results of usual care for achieving a low-density lipoprotein cholesterol (LDL) goal of 100 mg/dl or less in outpatients with documented coronary heart disease (CHD) who are not at goal, and to document the effect on LDL after removal of such a collaborative model from the study population. Prospective, multiclinic, controlled study. Four clinics of a 19-clinic staff model health maintenance organization in Minneapolis and St. Paul, Minnesota. Two clinics treated the intervention patients, two the controls; one clinic for each group was suburban, and one for each was urban. Four hundred eighty-one patients aged 18 years or older with CHD and whose LDL levels were not at goal. Clinical pharmacists implemented the physician-approved care plan for each intervention patient; activities included managing lipid-lowering drug therapy and educating patients on cardiovascular risk reduction. Primary outcomes were changes in LDL level and the proportion of patients achieving goal LDL in the intervention versus the usual care (control) group. Secondary outcomes were the sustainability of the impact observed up to 18 months after discontinuation of the intervention. Mean+/-SD baseline LDL levels were 131+/-28 and 131+/-26 mg/dl (p=NS) for the intervention and control groups, respectively. After a mean of 6.5 months follow-up, 107 (72%) patients in the intervention group and 61 (18%) patients in the control group had attained their LDL goal (p<0.001). Mean LDL levels were reduced by 35.6 mg/dl (27.5%) and 6.7 mg/dl (4.6%) in the intervention and control groups, respectively (p<0.001). When the active program was discontinued, results of the 18-month follow-up indicated that 85 (65%) intervention patients remained at goal compared with 96 (42%) controls (p<0.001). This trial provides quantitative evidence to support the effectiveness of the collaborative approach as an intervention to optimize management of patients with CHD whose LDL levels are not at goal; this approach is specifically called for in the executive summary of the National Cholesterol Education Program Adult Treatment Panel III. Furthermore, this study documents both the magnitude and sustainability of the impact collaborative care models can have in managed care environments.